APPLICATION FOR CERTIFICATION PROFESSIONAL STUDENT EXCHANGE PROGRAM

Transcription

1 North Dakota University System 1815 Schafer St. Ste. 202 Bismarck, ND Phone: APPLICATION FOR CERTIFICATION PROFESSIONAL STUDENT EXCHANGE PROGRAM Complete applications should be mailed to the above address. FOR OFFICE USE ONLY: Certified Alternate Certified Not Certified of Action Reviewer Check the Program(s) for which you are applying: Dentistry Optometry Veterinary Medicine This application for certification is being filed in anticipation of training beginning Fall. Year Professional program grade level you will be entering: Freshman Sophomore Junior Senior Name Last First Middle address Social Security Number Present Address Permanent Address List the institutions to which you are applying for professional training. Please contact our office if your institution choices change I hereby certify that the information contained on this application and in the Application for Resident Status is true and correct. I understand that I have specific responsibilities to the colleges to which I apply and to the NDUS. I have read the section of the WICHE Professional Student Exchange Program website entitled "How to Apply", and NDUS Procedure and I agree to adhere to the steps described therein in a timely manner. of Applicant SEX RACE For statistical purposes only relating to program evaluation.

2 COLLEGES NORTH DAKOTA STUDENTS MAY ATTEND THROUGH THE PROFESSIONAL STUDENT EXCHANGE PROGRAM DENTISTRY A.T. Still University Arizona & Oral Health Loma Linda University Midwestern University, Glendale Campus College of Dental Medicine Oregon Health and Science University University of California, Los Angeles University of California, San Francisco University of Colorado Health Sciences Center University of Nevada, Las Vegas University of Southern California School of Dental Medicine University of the Pacific University of Washington Western University of Health Sciences College of Dental Medicine University of Minnesota* Creighton University* Marquette University* University of Nebraska* OPTOMETRY Midwestern University, Glendale Campus, Arizona College of Optometry Pacific University College of Optometry Southern California College of Optometry Western University of Health Sciences College of Optometry Illinois College of Optometry* Colorado State University College of Veterinary Medicine & Biomedical Sciences Oregon State University College of Veterinary Medicine University of California, Davis** School of Veterinary Medicine VETERINARY MEDICINE Washington State University College of Veterinary Medicine University of Minnesota* Kansas State University * Iowa State University * * These schools are not WICHE participants, but they have established agreements directly with North Dakota for the PSEP program. Non WICHE participating schools may be funded at a different rate. **UC Davis does not rank WICHE applicants and WICHE students cannot take WICHE support to UC Davis SVM. Rather, UC Davis accepts up to two students from the WICHE states per year. Students admitted to UCD pay nonresident in year one and can apply for CA residency for years two through four.

3 RETURN FORM TO: North Dakota University System 1815 Schafer St #202 Bismarck ND FOR OFFICE USE ONLY: Application Approved Not Approved of Action Reviewing Party Reciprocity WUE PSEP Residency NORTH DAKOTA UNIVERSITY SYSTEM Application for Resident Student Status A. Introduction (Before filling in blanks, read the following carefully.) The representations made in this application are made for the purpose of determining legal residency for tuition purposes. All statements are subject to investigation and verification. Any false statement or omission made for the purpose of misleading or defrauding an institution constitutes grounds for expulsion and is punishable as a Class A Misdemeanor (for which the maximum penalty is one year's imprisonment or a $1,000 fine or both). 1. Full Name of Student Social Security Number* 2. Home Address Note: PO Box is not acceptable in determining ND residency Current Mailing Address street city state zip telephone # street city state zip telephone # 3. List all institutions of higher education that you have attended during the last three years, the dates of attendance at each, and whether you paid a resident or nonresident tuition (indicate N/A on that line if no distinction was made by the institution). Institution s of Attendance Resident or Nonresident 4. What is your country of citizenship? If other than U.S., state the type, number, and date of issue of your current visa. B. Resident Student Status I claim residency for tuition purposes because (check the section (or sections) under which you qualify and supply all information requested for that section): a. I am a person whose custodial parent, guardian, or parents has been a legal resident of North Dakota for 12 months immediately prior to the beginning of the academic term. Name of custodial parent or guardian Address (last 12 months) b. I am 18 years of age or older, and have been a legal resident of North Dakota for 12 months immediately prior to the beginning of the academic term. Address (last 12 months) * Disclosure of your Social Security number is voluntary. Social Security numbers are used as an individual ID number for record keeping and administrative purposes. If you do not disclose your Social Security number, an individual ID number will be assigned. OVER

4 c. I am a dependent child whose parent or guardian has been a legal resident of North Dakota for 12 months immediately prior to the beginning of the academic term or resides in the state with the intent to establish residency in the state for a period of years. Attach copy of first page of parent's most recent federal income tax return). Name of parent or guardian Parent's Address If parent has resided in North Dakota for less than 12 months: Place of Employment moved to North Dakota d. I graduated from a North Dakota high school. High School e. I am a full-time active duty member of the armed forces or a member of a North Dakota national guard unit. Branch Expected date of termination of that assignment Installation f. I am a spouse or a dependent of a full-time active duty member of the armed forces or a member of a North Dakota national guard unit. (If you are a dependent child, attach the first page of your parent s most recent federal income tax return.) Name of spouse or parent Branch Expected date of termination of that assignment Installation g. I am a veteran or spouse of a veteran as defined in NDCC Section (Attach a copy of your or your spouse s DD Form 214). h. I am a spouse or a dependent of an employee of an institution of higher education in the state. (If you are a dependent child, attach the first page of your parent s most recent federal income tax return.) Name of spouse or parent Address Institution i. I am married to a person who is a resident for tuition purposes (complete this section only if you do not qualify under one of the above sections). Name of spouse Address j. I was a legal resident of this state for at least 3 consecutive years within 6 years prior to the beginning of the academic term (complete this section only if you do not qualify under one of the above sections). List all places and dates of residence during the past 6 years: k. I am a child, stepchild, widow, or widower of a veteran who was killed in action or died from wounds or other serviceconnected causes, was totally disabled as a result of service-connected causes, died from service-connected disabilities, was a prisoner of war, or was declared missing in action. (If you are a dependent child, attach the first page of your parent s most recent federal income tax return.) Name of spouse or parent Address I hereby certify that the foregoing answers to the above questions are to the best of my knowledge and belief, true and correct; and that they accurately reflect my status at the present time. of Student Financial Aid/Reciprocity/Application for resident student status Nov 2012.docx Updated with language approved during the 2009 Legislative Session SB2082

5 CONSENT To Transfer Student Records through the Student Exchange Program Western Interstate Commission for Higher Education PURPOSE FOR REQUESTING STUDENT SIGNATURE ON CONSENT AND WAIVER FORM: Public Law , the Federal Family Educational Rights and Privacy Act of 1974, requires all who hold custody of student records to insure protection of personally identifiable information. Administration of WICHE Student Exchange Program requires the exchange of educational information about student applicants in order to provide for consideration of enrollment and transfer of funds by the state in the case of admission by the school. In order to facilitate exchange of necessary documents, the student applicant is asked to sign a Consent and Waiver" statement Student willingness to sign a consent statement is not a requirement for participation in the program. DESCRIPTION OF USE OF PERSONAL RECORDS: The program collects and uses information concerning student eligibility for the program; admission; enrollment; academic progress; graduation and/or termination from the professional program; and payment of fees by the state through WICHE to the receiving school. This information is exchanged between and among the certifying office of the student s home state; the staff of the Student Exchange Program, Western Interstate Commission for Higher Education; and the professional school(s) to which the student makes application and is admitted. The WICHE Commissioners of the sponsoring state may also review applications to consider eligibility of student(s). Periodic accounting for the Student Exchange Program in the state and in the region may result in publication of reports which may contain the student s name, home address, year of enrollment, enrolling institution, and money spent by the state to support the student s effort to reach an educational objective. NOTIFICATION CONCERNING STUDENT ACCESS TO PERSONAL RECORDS: Any student participant or applicant for participation in the Student Exchange Program has access to his/her personal records maintained as a part of the exchange activity. He/she may inspect and/or receive copies at a cost not to exceed the actual cost of reproduction. CONSENT AND WAIVER I understand that it is necessary to process student records in order to carry out the purpose of the Student Exchange Program, providing access to educational opportunities for residents of the western states. I understand that the record-keeping process requires preparation, transmission, receipt, filing, and reporting of information appropriate to the effectiveness and continuity of the program. I hereby consent to the transfer of personally identifiable educational records between and among the participants in the Student Exchange Program of the Western Interstate Commission for Higher Education to include the following: Information concerning student eligibility, acceptance, and educational attainment Information concerning fees paid by the sending state through WICHE to the receiving school Lists of applicants certified as eligible for support Admissions reports, withdrawal reports, and annual reports for WICHE Exchange Students Support Agreement forms and invoices Special letters of inquiry and response as required to address questions and concerns identified by program participants I understand that the information referred to herein will be available only to Student Exchange Program staff members, designated institutional officials, and sending state officials as required to carry out their official duties. I further consent to the transfer of all or a portion of the above educational records to admissions officers and certifying officers as required to accommodate the needs of the Student Exchange Program provided that the officers receiving the information will not permit any other party to have access to such information without the express written consent of the undersigned. I hereby waive my right to receive specific notification of the transfer of such records. I understand that personally identifiable educational records will be used only to the extent necessary to carry out the purposes of the Student Exchange Program including reasonable research studies necessary to evaluate and improve the program. Any general research report of information that might prove harmful or embarrassing will be included only when anonymity is preserved. Use of the information will be permitted only when, in the judgment of the Student Exchange Program director or other designated staff member, the request for information is wholly consistent with my best interests and the purposes of the Student Exchange Program. I understand that a log will be maintained to identify access to my records which is permitted pursuant to law, and this information will be available to me upon appropriate request a locked file will be maintained for the regular storage and protection of personal educational records. Name Permanent Address (Please print) (Street) (City) (State) (Zip)

6 VETERINARY MEDICINE APPLICANTS ONLY Professional Student Exchange Program Policy ACKNOWLEDGEMENT FORM I understand that I must inform the NDUS of my acceptance or declination of an offer of admission to a College of Veterinary Medicine by April 1 of the year of offer. I further understand that my failure to so notify the NDUS by April 1 may result in the loss of eligibility for support under PSEP. Name (Please Print) Permanent Address City, State, Zip STATEMENT OF INTENT Certification for eligibility of support at all cooperating veterinary medical programs is based on the understanding that you are committed to remain in the degree program from the time of your first enrollment until completion of the course of study. Therefore, we have been requested to secure the following signed statement from each North Dakota certified veterinary medicine applicant: As a certified WICHE applicant, I am aware that if the State of North Dakota pays support fees to defray the cost of my veterinary medical education. If admitted under the PSEP program, I am committed to pursue my studies in veterinary medicine as a supported exchange student without voluntary interruption until I have qualified for my degree. STATEMENT OF UNDERSTANDING I,, understand that offers for support will be made to certified WICHE applicants based on the availability of funding from each state. Offers will be made according to a collective ranking of students by the participating veterinary medicine schools. It is to my advantage to apply to all cooperating institutions to be considered for admission. If I choose to apply to fewer than all programs, I risk receiving less than full consideration for available funding. Note: You are encouraged to keep a copy of this statement for your records.